GMC publishes new guidance for doctors supervising physician associates

The GMC has published new guidance for doctors supervising physician associates (PAs), however GP leaders warned it failed to account for the ‘very specific risk environment’ in general practice.

The new guidance, published yesterday, brings together ‘key principles’ from the standards document Good Medical Practice and other ‘relevant guidance’ into a single resource, the GMC said.

The guidance, developed ‘with input from doctors who supervise PAs’, said that PAs should work under the overall supervision of a ‘named senior doctor’, usually a GP, consultant or autonomously practising SAS doctor, who ‘will have a clear understanding of their competence, skills and experience’.

While the GMC has said it will not set out a scope for PAs, the document said duties performed by PAs may include:

• taking medical histories from patients
• performing physical examinations
• diagnosing illnesses
• seeing patients with long-term chronic conditions
• performing diagnostic and therapeutic procedures
• analysing test results
• developing management plans
• providing health promotion and disease prevention advice for patients.

The guidance also sought to address accountability for the actions of PAs. It said doctors ‘are accountable for the actions, steps, and decisions that you take’. 

‘If you are the responsible consultant or clinician, you are also accountable for the overall management of a patient,’ it added.

However, ‘PAs and AAs are accountable for the actions, steps and decisions they take to prioritise patient safety’; and they ‘are under professional obligations to recognise and work within the limits of their competence and to seek help if they are not confident they have the knowledge, skills, or training to carry out a task safely’ – ‘even if they have already agreed to carry out the task independently’.

The guidance also said it was ‘vital’ for doctors supervising PAs to ‘encourage’ them to ‘seek clarification or ask questions’.

‘This is especially important if they express uncertainty or a lack of confidence. This will make sure they feel safe to communicate concerns and are supported in resolving any issues.’

‘It is also your responsibility to foster an open and safe environment for PAs, AAs and others in the healthcare team,’ the guidance added.

‘This means it is important to listen, communicate clearly, recognise their contribution and be willing to lead or follow as the circumstances require.’

The guidance also made recommendations for doctors in seeking to establish what level of care a PA is capable of providing to patients (see box).

Last year, the RCGP set out a scope for PAs that severely limited their practice, stipulating that PAs must not see patients who have not been triaged by a GP, nor patients who present for a second time with an unresolved issue.

Referring to this and other guidance documents, the new GMC guidance said: ‘Some royal colleges and PA and AA professional bodies have published interim guidance on post-qualification scope of practice. Though there is no set consensus, you may find them helpful as a starting point. The Leng Review is also likely to make recommendations in this area later in 2025.’

The independent Leng review into physician associates ordered by the Government is due to report in June. Led by Professor Gillian Leng, the review’s main task is to determine if PAs and AAs ‘are safe and effective as members of a multidisciplinary team, across all tasks, roles and settings’.

But it will also consider supervision and oversight, including ‘best practice’ for PAs and ‘optimal’ staff ratios, and set out who should have responsibility in the health system in relation to setting out guidance and standards on training and working for the profession, to address ‘current confusion in leadership roles’.

Commenting on the new GMC guidance, RCGP told Pulse it was ‘disappointed’ that it does not account ‘for the very specific risk environment in general practice’. It also said that some of the duties of a PA listed in the guidance had been objected to by the college.

RCGP chair Professor Kamila Hawthorne said: ‘It is the college’s position, following consultation with members and discussion amongst our governing council, that physician associates do not have a role in a general practice setting.

‘However, acknowledging that there are around 2,000 PAs already working in general practice, we have produced guidance for practices on induction, supervision and scope of practice for practices that do employ PAs. 

‘It is also our position that whilst regulation of PAs is vital, the GMC is not the most appropriate regulator. However, as their regulation of PAs has already begun, we have always said we would work with them in order for regulation to be as safe and appropriate as possible.

‘While we are pleased that the GMC has referenced our supervision guidance in their own resource, we are disappointed that it doesn’t account for the very specific risk environment in general practice – and the college’s objections to some of the duties listed – which we raised with them during the development of this resource.’

Professor Azeem Majeed, a GP and head of primary care and public health at Imperial College London, said the ‘complex’ issue of PA scope is not addressed clearly in the new guidance.

He said: ‘The guidance acknowledges that PAs are accountable for their own actions, while doctors remain responsible for the overall management of a patient when they are the responsible clinician.

‘However, in practice, this division of responsibility is not always straightforward. A key issue will be how the “scope of practice” for PAs and AAs is defined and implemented.

‘If the scope of practice is broad and these professionals work largely independently, then supervising doctors will face greater medicolegal risks.

‘If their scope is narrow and they work under close supervision, the medicolegal risks to doctors will be reduced but so too will the value that PAs and AAs add to the clinical team.

‘This tension is at the heart of the ongoing debate about the role of PAs and AAs in the NHS. To truly contribute to care pathways and alleviate workforce pressures, PAs and AAs need to function autonomously.

‘But that autonomy must be balanced with clear lines of accountability and appropriate regulatory safeguards to protect both patients and professionals. Without this clarity, both doctors and employers will be placed in difficult positions.’

Doctors Association UK GP spokesperson Dr Steve Taylor agreed that the guidance ‘fails to address’ important issues in the supervision of PAs.

He told Pulse: ‘In many cases the supervisor will not have sufficient knowledge of the PA’s training, knowledge, or capabilities.

‘Because the supervisor retains responsibility and accountability for patient care, the supervisor will need to be confident that the patient is being treated appropriately, safely and has been thoroughly accessed.

‘Supervision is not straightforward and currently there are no training requirements for supervisors. This means patients primarily, PAs and doctors are being placed in positions that are not ideal at best and unsafe at worst.’

A GMC spokesperson said: ‘We have launched a new resource to support doctors who supervise physician associates (PAs) and anaesthesia associates (AAs).

‘These ethical hub pages don’t set any new standards, but reflect our existing guidance and provide good practice advice and support for doctors with supervision duties to apply our professional standards in practice.

‘The resource covers topics like working with PAs and AAs, the role of the named supervisor and day-to-day supervision, and also signposts them to other sources of information and support.

‘Throughout the development of our ethical hub we engaged with a wide set of stakeholders, including royal colleges, doctors with supervision duties and PAs and AAs, balancing a range of feedback to produce the final content.’